Cycle 1
Health 2025-01-24 · Fire 2025-01-24
6 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
San Antonio, TX
Mystic Park Nursing & Rehabilitation Center
4-star overall rating with 3-star inspections with $111,121 in total fines with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
8503 Mystic Park, San Antonio, TX
(210) 256-0906
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
119
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2004-04-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.42
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.28
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.77
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.57
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,446
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.72
Composite VBP score used to determine payment impact.
Payment multiplier
0.9843
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.49% · Performance 22.20% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.58
Baseline 6.20% · Performance 6.77% · Measure score 3.58 · Achievement 3.58 · Improvement 0
Total nurse turnover
6.22
Performance 38.27% · Measure score 6.22 · Achievement 6.22 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.89
Baseline 2.86 hours · Performance 3.27 hours · Measure score 0.89 · Achievement 0.67 · Improvement 0.89
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.09% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 89 · Observed rate 7.87% · Lower 95% interval 7.01% |
| Discharge to community | 54.93% |
50.57%
4.4 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 49.06% · Lower 95% interval 42.36% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 85.19% |
95.27%
10.1 pts worse
|
Numerator 46 · Denominator 54 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 54 |
| Discharge self-care score | 45.71% |
53.69%
8 pts worse
|
Numerator 16 · Denominator 35 |
| Discharge mobility score | 40% |
50.94%
10.9 pts worse
|
Numerator 14 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 54 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.77% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 6.67% · Lower 95% interval 3.86% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 150 |
| Staff flu vaccination coverage | 91.94% |
42%
49.9 pts better
|
Numerator 194 · Denominator 211 |
| Discharge function score | 51.43% |
56.45%
5 pts worse
|
Numerator 18 · Denominator 35 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 23.08% |
25.2%
2.1 pts worse
|
Numerator 6 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.3%
1 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.3% · Q3 5.3% · Q4 4.3% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
2.7%
0.2 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.3% · Q3 3.3% · Q4 1.1% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
3.3%
2.3 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 1.3% · Q4 1.3% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
18.9%
2.9 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 14.7% · Q3 17.6% · Q4 16.2% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.8% |
10.8%
3 pts better
|
16.7%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 5.8% · Q3 5.1% · Q4 7.0% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.8% |
0.0%
0.8 pts worse
|
0.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.1% · Q4 1.1% · 4Q avg 0.8% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.0% |
15.4%
3.4 pts better
|
16.3%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 14.4% · Q3 10.6% · Q4 2.8% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
16.1%
7.4 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 4.5% · Q3 7.9% · Q4 1.4% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.5% |
15.0%
4.5 pts worse
|
19.8%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 33.4% · Q2 17.0% · Q3 14.9% · Q4 13.0% · 4Q avg 19.5% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.2%
1.9 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.8% · Q3 2.9% · Q4 2.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
89.7%
9.7 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.1% · Q4 98.3% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
12.0%
1.2 pts better
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 10.9% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.4% |
88.0%
10.4 pts better
|
79.7%
18.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
25.9%
2.5 pts better
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 19.6% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-08 · Fire 2023-12-08
7 health deficiencies
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-10-14 · Fire 2022-10-14
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-02-17
E · Potential for more than minimal harm
2025-01-24
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-01-29
E · Potential for more than minimal harm
2025-01-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-12
E · Potential for more than minimal harm
2025-01-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-12
E · Potential for more than minimal harm
2025-01-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-12
E · Potential for more than minimal harm
2025-01-24
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-28
F · Potential for more than minimal harm
2023-12-08
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2023-12-13
F · Potential for more than minimal harm
2023-12-08
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-12-13
F · Potential for more than minimal harm
2023-12-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-13
F · Potential for more than minimal harm
2022-10-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-06
D · Potential for more than minimal harm
2025-01-24
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-06
D · Potential for more than minimal harm
2025-01-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-06
D · Potential for more than minimal harm
2025-01-24
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-02-06
D · Potential for more than minimal harm
2025-01-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-06
D · Potential for more than minimal harm
2025-01-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-06
D · Potential for more than minimal harm
2024-12-19
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-01-07
D · Potential for more than minimal harm
2024-12-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-07
K · Immediate jeopardy
2024-04-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-29
K · Immediate jeopardy
2024-04-28
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-04-29
E · Potential for more than minimal harm
2023-12-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-13
D · Potential for more than minimal harm
2023-12-08
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-12-13
D · Potential for more than minimal harm
2023-12-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-13
F · Potential for more than minimal harm
2022-10-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-14
E · Potential for more than minimal harm
2022-10-14
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-11-14
E · Potential for more than minimal harm
2022-10-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-14
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-14
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2022-11-14
C · Minimal harm
2022-10-14
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2022-11-14
Penalties and ownership
What sits behind the stars
$111,121
2024-04-28
Fine
Fine · fine $111,121
Fine
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Brewer, Devin
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Fox Sparrow Healthcare, Inc.
Operational/Managerial Control · Organization
Keetch, Chad
Corporate Officer · Individual
Thompson, Johnny
Corporate Officer · Individual
Zantua, Omar
Operational/Managerial Control · Individual
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#2
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3-star overall rating with 2-star inspections with 20 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
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